Stroke Rounds: Are Oldest Patients Getting Too Many Drugs?

Action Points

The author suggests that for patients over the age of 80 the literature indicates that the risks associated with the use of statins and hypertensives for primary prevention outweigh the potential benefits.

The author suggests that these medications are greatly overprescribed in the healthy elderly and largely irrelevant in the frail elderly, and we should require that the patient should be actively involved in the decision-making process.

Too many healthy people in their 80s and older are being treated with statins and antihypertensives for stroke prevention, according to British commentary in Evidence-Based Medicine.

And in those who are old and frail, the drugs are "largely irrelevant" for preventing strokes, wrote Kit Byatt, a geriatric medicine physician at Hereford County Hospital in England.

"The epidemiology suggests that, by this age, hypertension is not an attributable risk factor for stroke, and hypercholesterolemia has little effect on stroke risk overall," he wrote. "The largest trials of antihypertensive therapy and statins in this age group show at best a marginal clinical reduction in stroke and very modest clinical reductions in other cardiovascular endpoints."

In addition, in the PROSPER study -- "arguably the definitive study of statins for stroke prevention in older people," according to Byatt -- treatment with pravastatin versus placebo reduced the composite of all strokes or cardiac events, but not strokes alone.

And on top of the lack of substantial benefit, there is some evidence that morbidity associated with statin use is under-reported, Byatt said.

"The data strongly suggest that we are overtreating many healthy patients aged 80+ regarding stroke prevention," he wrote.

"We need actively to rethink our priorities and beliefs about stroke prevention, actively informing and involving the views of the key person, the patient," he wrote. "Most of the patients will probably eschew the modest potential benefit, preferring the reduced burden of polypharmacy and side effects judged as 'minor' by the prescriber."

Most of the patients in hypertension trials were younger than 80, however.

"Pooling the limited number of octogenarians from several trials mainly composed of younger patients, treated patients showed a reduction in both stroke and cardiovascular morbidity, but a trend toward increased all-cause mortality compared to controls," the authors of the statement wrote. "Thus, the overall benefits of treating octogenarians remain unclear despite epidemiological evidence that hypertension remains a potent cardiovascular risk factor in this age group."

The reactions of several U.S. cardiologists contacted by MedPage Today to Byatt's perspective were mixed.

William O'Neill, MD, of Henry Ford Hospital, supported Byatt's viewpoint, saying in an email, "I wholeheartedly agree with the author that we over-prescribe medications in elderly, asymptomatic elders. I never start patients in their 80s on statins for primary prevention. If they have not had a cardiac event by that age, it is unlikely that they will during their life. Antihypertensives can cause severe orthostatic hypotension and I am very conservative with these agents."

Also, "the polypharmacy that occurs with elders can be described as unsafe practice," he continued. "I often see patients coming in with 15 to 20 different medications they are supposed to take. I honestly don't know how they keep the medicines straight. I try to limit meds to three or four at most, and ideally at a once-a-day dose."

Other clinicians took issue with Byatt's dismissal of the importance of hypertension and of antihypertensive treatment in the oldest patients.

Daniel Lackland, DrPH, of the Medical University of South Carolina, responded to Byatt’s statement that hypertension is not an attributable risk factor for stroke by the time people reach age 80 by saying, "I do not feel that is a valid evidence-based statement. Elevated blood pressure is a stroke and cardiovascular disease risk factor at all ages, including the very old.">

But, added Lackland, who was speaking for the American Heart Association, "In the elderly, there is little evidence of the benefit of blood pressure reduction."

Byatt "failed to point out the increasingly important role that atrial fibrillation plays in stroke in the elderly (as many as one in three strokes in octogenarians have an association with atrial fibrillation)," commented John Erwin III, MD, of the Scott & White Heart and Vascular Institute in Temple, Texas. “The prevalence of atrial fibrillation is certainly increased in poorly controlled hypertensive people."

Ken Uchino, MD, of the Cleveland Clinic, said, "I disagree with the author in de-emphasizing hypertension."

"We cannot assume that because the contribution of hypertension is smaller as one gets older, that treatment would not reduce stroke," he said.

Others, like Adam Skolnick, MD, of NYU Langone Medical Center, stressed that a distinction had to be made between primary prevention and secondary prevention.

"While for an older individual without known cardiovascular disease and without significant risk factors, these medications may not be indicated as primary prevention, for those patients with known cardiovascular disease they may prevent a disabling stroke or myocardial infarction," he said. "If a patient has a prognosis greater than a year and has known cardiovascular disease, they should not be denied these therapies that have been proven to prevent cardiovascular events, which may reduce quality of life and independence."

"For patients with known history of atherosclerotic cardiovascular disease or stroke, treatment with cholesterol-lowering statin medications and treatment of high blood pressure remain the most effective treatments that we have for reducing stroke and mortality," he said.

Stone, who served as chair of the expert panel in charge of the cholesterol guidance, said that the guidelines do not make firm recommendations about the use of statins in patients older than 75 because of the relative lack of data in the oldest patients.

"But we recognize there could be factors where the patient and the physician may decide to use statin treatment," he said, pointing to patients who were already taking a statin or those with diabetes as examples.

He stressed that the discussion between the clinician and patient about the risks and benefits of therapy is key for all age groups, although it may be more important for those older than 75.

"That's because when there's very little data, I think we need to absolutely include the patient into this decision and let the patient know what it's based on," he said.

Other clinicians echoed the importance of individualizing treatment decisions in the older age groups.

"It is always a case-by-case decision,” according to Erwin. “One is certainly going to treat a severely demented, fall-prone patient or a patient with metastatic cancer differently than one would an otherwise active and vibrant octogenarian. All 80-year-olds are not created equally."

John Higgins MD, MBA, of the University of Texas Health Science Center at Houston (UTHealth), said that he believed statins and antihypertensives were used appropriately in all age groups in the U.S., but he also supported the need for a discussion between the patient and his or her doctor.

"While there are guidelines that aid in management, ultimately it is an individual decision between the physician and the patient, after weighing the risks and benefits of treatment as well as factoring in the patient's quality of life, other medical conditions, risks for stroke and heart attack, and life expectancy," he said.

UPDATE: This article, originally published on Feb. 27 at 15:15 EST was updated with new material at 17:15 EST.

Byatt disclosed no relevant relationships with industry.

Reviewed by Zalman S. Agus, MD Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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